ADVANCED ORTHOPEDICS & SPORTS MEDICINE, P.A.

NAME: _______________________________________ Today’s Date: ____________

Height: __________________ Weight: ________________

CHIEF COMPLAINT

Why are you seeing the doctor today? _________________________________________

Current problem is the result of a(n): CHECK all that apply

5 Car injury 5 Work injury 5 Other injury 5 No Injury

mo/day/yr

Date of injury / / Describe accident __________________________

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List current medications: ____________________________________________________________

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List allergies: _____________________________________________________________________

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List surgeries/operations: ____________________________________________________________
_________________________________________________________________________________

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SOCIAL HISTORY

5 Caffeine-how much _________ 5 Tobacco-how much __________
5 Alcohol-how much __________ 5 exercise-what & how often __________

FAMILY HISTORY

	Health Condition	Age	Living/Deceased	Cause of Death
Father
Mother
Brother(s)
Sister(s)